Denied coverage for treatment. Now what?

[Barney]

UnitedHealthCare (UHC) has now twice denied coverage of my GI doctor's recommended treatment of Sovaldi/Olysio. Next week my employer's option to change insurance companies for 2015 ends.

First some background:
2005
Diagnosed with Hep C, genotype 1. Liver biopsy showed level 2 scarring.
GI doctor recommended against currently-available treatments due to poor cure rate. Said to wait for new treatments on the horizon.
2013
October 2013 CT scan for acute appendicitis revealed more extensive liver damage, plus signs of portal hypertension. Had appendix surgeon perform liver biopsy, which showed level 4 scarring (cirrhosis).
2014
May 2014 admitted to ER/ICU for internal bleeding in stomach. While not conclusively attributed to variceal bleeding, cirrhosis/portal hypertension likely cause.
August 2014 GI doctor submits pre-authorization request to UHC for Sovaldi/Olysio.
Sept. 2014 UHC denies both. Reasons: Sovaldi- The doctor did not show that "Sovaldi will be used in combination with Ribavirin" , Olysio- "Must present evidence ...your patient is without decompensated liver disease".
GI doctor appeals.
Sept. 2014 UHC denies appeal, stating doctor "must submit: 1) a documented reason why you cannot take Perinterferon and: 2) you doctor must supply documentation that you are not using alcohol or illegal drugs". I don't drink or use illegal drugs, but because they didn't define what evidence is required, that seems like an open-ended battle.

So my questions are:

• Is this the "normal" process and I should expect that UHC will likely make me jump through more hoops after each denial before eventually authorizing treatment? The possibility exists that they will never authorize it.
• Which insurance companies have recently shown better acceptance of modern Hep C treatment requests?
• I'm aware that there are co-pay and patient assistance options available for those that qualify, but I'd prefer to exhaust all insurance options before going down that path.

Thanks!

[willie g]

HELLO BARNEY I am going to give you one of the most important words you will have to learn with approval, starting meds[which please relax because I had to and most of us had to become pretty good LOOP jumpers] etc.  that word my friend is PATIENCE!  [you probably want to slap me right now or have a comment in your head like ,PATIENCE MY ASS !]  but fortunately all that stuff your worrying about right now will all be in your past soon to come, sooner for this one and sooner for others but I must say since I have been around[boy have I , but that's another story lol] I cant think of anyone that hasn't had things all worked out in the end!  at least 85 % of the crap we worry about in life is all bull,and I mean bull, the other 15% or so we HAVE NO CONTROL over, so whats that tell you?  yup, DONT WORRY BE HAPPY[now ill take that slap ha ha] but it is true, I have the facts to prove it    ME !    so again welcome check back Monday and a lot of smart people will have your questions answered in no time and a bunch of idiot [notice I didn't put an s at the end of that word]  will try and be as helpful as they possibly can,, great forum,,,, you come back now , here?   ''just'' Willie g  saying hi to BARNEY

[lporterrn]

Hi Barney,
Thank you for making my blood pressure rise - this sort of issue tries my patience. Thank goodness I read Willie's wisdom.

You asked:
Is this the "normal" process and I should expect that UHC will likely make me jump through more hoops after each denial before eventually authorizing treatment? The possibility exists that they will never authorize it.
Normal, yes (although I am reluctant to embrace this as the new normal) - you will need to show platelets and a tox screen. Your doc can enhance the process by stating you have depression, sicca complex, or aches and pains (assuming you have them that will be worsened by interferon).

Which insurance companies have recently shown better acceptance of modern Hep C treatment requests?
I am hearing problems all over the country - appears to be state by state. I suggest you post a new question to the forum, asking people in your state to say what insurance plan they have succeeded in getting treatment approved.

I'm aware that there are co-pay and patient assistance options available for those that qualify, but I'd prefer to exhaust all insurance options before going down that path. Good idea - or, you can contact (or have your doc contact) the patient assistance programs and help you with the insurance process - I highly recommend this.

One more thought - in less than 2 weeks, the combo pill Sovaldi/ledipasivr is expected to be approved. Since it won't be "off-label" you should be able to qualify without having to prove interferon-intolerance. I think the tox screen is illegal, but that is for the courts to decide, and not your battle. FYI, even trace marijuana shows up, so be sure you are squeaky clean. 

Keep in touch - Willie will keep us sane.

[Barney]

Thanks for your input!

I was really hoping other forum contributors would chime in on which insurance companies are approving treatment. I have about 10 days to decide on who my carrier will be for 2015. After the two denials, my next step with UHC is an external review, and after that, contacting the insurance division for Illinois (my employer's state).

The new Gilead LDV/SOF combo pill (aka Harvoni in Europe) should eliminate UHC's reservation about off-label use. I would also hope the price will be less than Solvaldi/Olysio because the treatment would come from a single manufacturer. Assuming the FDA approves LDV/SOF on October 10, pricing and availability are anybody's guess.

[willie g]

cvs/caremart is who I go thru BARNEY, its kinda like your drs. assistance guy that handles insurance etc. should help you with that  and I don't know if you have tried the biggest dictionary in the world which is the internet,, google whatever question you have about anything and you will get a site to go to. you may have to reword your question here and ther but there are tons of people out there in the same boat with ideas and answers from all over the world. don't depend on just one forum or website,, just my opinion but it works for me  ''just'' willie g   im prayin for ya right now barney,, it will work, i  know your rowing the boat damit but get a motor if you have too its great you ask, id be concerned too,, prayer helps for me buddy

[Mike]

Hi Barney,

Your struggle is fairly common - especially for off-label treatments.

This can become more problematic during open enrollment for insurance, as insurance companies know that coverage, policies and insurance providers may change (note: open enrollment runs through the entire month of Oct., and changes have to be made before Nov 1st).  New policy providers (or changes in current coverage with the same insurer) become effective Jan 1st.

This means the current insurance policy and insurer  remain in effect through Dec 30th (provided the premium is paid).

Insurers are reluctant to approve expensive elective treatments knowing that everything will change on Jan 1st (including premium costs if you keep your same coverage).

Another factor is: In most cases, Hep-C is an elective treatment which is why an insurer can ask for additional medical documentation and require specific disease progression before approving.

Insurers also know that approval can be "pended" until additional documentation is received, reviewed and a final determination can be issued (denied/approved). This can also be used as a stall tactic.

Since current Hep-C treatment is a minimum of 90 days in length, the insurer does not want to approve a 90 day elective treatment when there is only 60 days left on the current policy. 

Simply put, your  insurer already knows that, at minimum, if you elect to keep your current policy for 2015, the premium is going to increase 10-50%. If the treatment cost is shifted  to 2015 - the less cost to the insurer (due to increased premium, for example).

In addition, your current insurer also knows that you may in fact elect to change insurance carriers for 2015, which means they would be completely off the hook for the treatment (as they will not approve a 90 day elective treatment when you only have, for instance, 45 days left on your current coverage with them).

It really boils down to risk, cost and profit.

Best wishes, Mike


   

[willie g]

Now that makes since Mike and there you go Barney,no internet needed,, such a good site. "Just" willie g